Sex: Age:Patient contact no.Diagnostic centre name :
Ghief Ministerts Gomprehensive Health lnsurance SchemeDate
:HospitalOP/IP no. :Name of the hospital :Doctor name :Doctors
registration no. :
Referral Slip no. :
1. Name of the patient :2. Age: Sex:3. District:4. Card no.5.
Presenting complaint :6. Significant past illness :7. Positive
clinicalfindings :8. Provisional diagnosis :9. lnvestigations in
support of diagnosis :'10. Diagnostic purpose referral :11.
Referred to : (Name of the diagnostic centre)Date :
HospitalOP/lP no. :Name of the hospital :
Town:Department:Doctor's name :Doctor's register no.
:Designation :Patient contact no. :
Name:Seal
Diagnostic procedure recommendeO : l-lGhief Ministerts
Gomprehensive Health lnsurance Scheme
United lndia lnsurance Co. Ltd.
United lndia lnsurance Co. Ltd.
Signature of the doctor
8/2/2019 Referral Slip
2/2
Toll Free No. : 1800 425 3993 Eligibility Griteria(a) Any Family
Whose annual income is less than Rs. 720001Referral Slip for
Diagnostic Procedures
Please Tick ( / ) the Required Procedure in the Box1. Angiogram
E2. ECHO tr3. Computed Tomogram (CT Scan) tr4. Magnetic Resonance
lmaging (MRl) tr5. Mammogram E6. Ultra Sound Guided Biopsy tr7.
Histopathology Examination tr8. Calposcopy trL Nuclear Bone Scan
E10. Tumour Markers E11. Bone Marrow Study tr12. Radio lsotope
Scanning E13. Diagnostic Laproscopy tr14. Diagnostic Thoracoscopy
tr15. lmmuno Histo Chemistry tr16. USG as an Emergency Procedure
ofFacility is not Available at GH tr17. Metabolic Screening E18.
Fundus Fluorescence Angiography tr19. Liver Function Test (LFT)
tr20. Renal Function Test (RFT) tr21. Thyroid Profile, Antithyrold
Antibodies tr22. Aortogram tr23. Karyotyping tr
